No Form Number (906) Texas Citrus Certificate of Privilege

OMB No. 0581-0189

TEXAS VALLEY CITRUS COMMITTEE
901 Business Park Drive, Suite 400
Mission, Texas 78572

Telephone: (956) 581-2190
Fax: (956) 584-3307

CERTIFICATE OF PRIVILEGE NO. __________
I, the undersigned, hereby certify to the Secretary of Agriculture and to the Texas Valley Citrus
Committee that I have read, fully understand, and will comply with, the foregoing rules that govern the
handling of citrus for processing or for manufacturing for conversion into specified by-products, relief or
charity. I further understand that noncompliance is a violation of the Agricultural Marketing Agreement
Act, and is subject to a fine of up to $3,147 for each violation.
By: ______________________________
Name (please print)

___________________________
Signature

Firm Name: ___________________________________

____________
Date

Title:____________________________

Address: ____________________________________________________________________________
Mailing Address, City, State, and Zip Code
Physical Address (if different than mailing address): __________________________________________
Phone: _______________________________

Fax: __________________________________

Person in charge of Special Purpose forms: _________________________________________________
Purpose of Shipments:  Processing

 Relief/Charity

(check applicable boxes)

 Otherwise Diverted ______________

Where will shipments originate? _________________________________________________________
List Names and Addresses of Consignees below:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
APPROVED BY: ______________________________________

DATE:____________________

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information
unless it displays a valid OMB control number. The valid OMB control number for this information collection is OMB 0581-0189. The time required to complete
this information collection is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and
employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex,
gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance
program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all
programs). Remedies and complaint filing deadlines vary by program or incident. Persons with disabilities who require alternative means of communication for
program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202)
720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in
languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information
requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of
Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
[email protected]. USDA is an equal opportunity provider, employer, and lender.

Exp. 12/31/2023. Destroy previous editions.